CALCULATING EXPENSES FOR A CLTS FOSTER HOME USING ACTUAL 
                                                          EXPENSES
                      Person completing this form:
                                  Date Completed:
                                                    Demographic Information 
                    Participant Name:                                                           Age:
                  Foster Home Name:
                   Number of Occupants in Home:
                       Type of Home:Place an 'x' next to type of home          Facility Total Monthly
                                                                                                   1
                                 Foster Home:                                Room and Board Rate :             #DIV/0!
                                                                             1
                                                                              This rate is calculated automatically in Section 3.
                   Level 5  Treatment Foster Home:
                                                                Child Welfare Rates:           Basic:
                                                                                      Supplemental:
                                                                                        Exceptional:
                              1. Calculation of Housing and Food Expenses: Using Actual Expenses
                                                                    Total Household        Total         Individual
                               Type of Expense                            Cost          Occupants         Amount
                    Rent, or Depreciation and Mortgage Interest, 
              Insurance (Title, Mortgage, Property and Casualty), 
                     Building and/or Grounds Maintenance Costs                               0                 #DIV/0!
                                  Food Budget for the Household                              0                 #DIV/0!
                                          Furnishings Supplied by
                                   Facility and Used by Residents                            0                 #DIV/0!
                                              Household Supplies                             0                 #DIV/0!
                                                         Electricity                         0                 #DIV/0!
                                                 Water and Sewer                             0                 #DIV/0!
                                                      Heating Fuel                           0                 #DIV/0!
                                                 House Telephone                             0                 #DIV/0!
                                                  Cable Television                           0                 #DIV/0!
                                                                                            1. Total=          #DIV/0!
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                                           2. Calculation of Participant- Specific Expenses
                             Complete this section only if this child has participant-specific expenses.
                                     If no specific expenses are needed, continue to Section #3.
                                                     Special Dietary Needs, Exceptional Utility Costs,
                                                          Personal Supplies, Other Personal Expenses
                                                                                               2. Total= 
                                                   3. Total Monthly Rate Summary
                                                                        Room and Board Expenses 1.=                 #DIV/0!
                                                      (If Applicable) Participant-Specific Expenses 2.=               $0.00
                                                                                                       2
                                                                               3. Total Monthly Rate =              #DIV/0!
                                                 2
                                                  This total is automatically placed in the "Facility Total Monthly Room & Board Rate."
                                4. Calculation of Housing and Food Expenses: Using the Basic Rate
             Use the Uniform Foster Care brochure to determine the percentage of Housing expenses and the percentage of Food expenses 
                                             applied to the Basic Rate based upon the child's age.
                                                                                                          Room and Board 
                                                                                                          Portion of Basic 
                                                                          Percentage        Basic Rate          Rate 
                                                             Housing                               $0.00              $0.00
                                                                Food                               $0.00              $0.00
                                                                 4.Total Basic Rate Room and Board =                  $0.00
                                                 5. Foster Care Checks and Balances
                                                                                                             Child Welfare 
                                                                                          Basic Rate Room   portion of Basic 
                                                                           Basic Rate         & Board            Rate
                                Child Welfare portion of Basic Rate
                                 (= Basic Rate minus Basic Rate Room & Board)      $0.00           $0.00              $0.00
                                                                                           Monthly Rate - 
                                                                                          Reduced Excep.    CLTS portion of  
                                                                        Exceptional Rate        rate          Excep. Rate
                                   CLTS portion of Exceptional Rate
                (= Exceptional Rate minus the difference between the Monthly Rate- $0.00         #DIV/0!            #DIV/0!
                                                     Household Expenses)
                                                  Supplemental rate                                                   $0.00
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                                                             6. Balancing of Expenses
                In the section below, the Foster Care/Child Welfare total should equal the CLTS Waiver Expenses total. This assures that the 
                               CLTS Waivers are not paying more for foster care than the total calculated by Child Welfare.
                                CLTS Waiver Expenses                                        Foster Care/Child Welfare
                                         Room & Board=              #DIV/0!                            Basic Rate=                 $0.00
                Child Welfare portion of Basic Rate=                   $0.00                 Supplemental Rate=                    $0.00
                                    Supplemental Rate=                 $0.00                   Exceptional Rate=                   $0.00
                  CLTS Allowable portion of Exceptional Rate        #DIV/0!
                                                    TOTAL           #DIV/0!                                  TOTAL                 $0.00
                                                      *The two totals above must match.*
                                                            7.  Information for the ISP
                                                                                                                             CLTS
                                                    Expense                                            Amount            Allowable?
                                                                                  Room & Board              #DIV/0!            N
                                                         Child Welfare portion of Basic Rate                  $0.00            N
                                                                            Supplemental Rate                 $0.00            Y
                                                CLTS Allowable portion of Exceptional Rate                  #DIV/0!            Y
                                                                    CLTS Administrative Costs3                                 Y
                                                         Child Welfare Administrative Costs3                                   N
                                                               3
                                                                 Administrative costs are only used for Level 5 and Treatment Foster Homes.
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